Chapter 5: Connecticut Dental Health Partnership Policy Standards of Care

The Connecticut Dental Health Partnership is committed to achieving Oral Health Equity. Our mission is to enable all HUSKY Health members to achieve and maintain good oral health. We work to ensure all members have equitable access to oral health services.

Dental Home 

“The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate. ” by the American Association of Pediatric Dentistry (AAPD) and the American Dental Association (ADA); both of which provide further information regarding services that constitute a dental home. The key features of a dental home are as follows:

• Provides comprehensive care (restoration of cavities, root canal therapy and extractions)including prevention and emergency services
• Care should be accessible, have a fixed location for follow up services, close to the client’s home and have regular appointment hours available by week
•  It should have a plan for providing emergency care available 24/7, other than providing a referral to the local emergency room
• It should have the capacity to make referrals to specialists if needed (and within the client’s network)
• Completes a disease risk assessment for each patient and uses it to design an individualized treatment plan
• Improves or maintains the patient’s oral health to a functional level

Appointment Scheduling

CTDHP has established the following scheduling standards:

• Emergency cases:  shall be seen within 24 hours, referred to another dentist or dental specialist or if necessary, referred to an emergency facility for immediate treatment
• Urgent cases should be seen within 48 hours of contact and is not dependent upon convenience for the patient
• Preventative and non-urgent or emergent care visits shall be scheduled within eight weeks of contact
• Specialists will provide treatment within the scope of their practice and within professionally accepted standards of care and promptness standards for providing such treatment
• Waiting times at primary care offices shall be kept to a minimum
• Per federal regulations, Medicaid clients cannot be charged for missed or cancelled appointments

In order to ensure the best possible client service, CTDHP asks that all provider offices make use of an answering machine and/or answering service during any hours that the office staff is unavailable to take calls. There must be a method available to patients to contact the provider in the event an emergency occurs; it is not sufficient to refer the client to the local emergency room.

Opening and Closing Panels

Provider offices may contact the CTDHP at any time to open or close panels to new client referrals or limit participation based on program, location or age. CTDHP encourages all general dental offices to consider accepting families, including the parents of children who are clients of the office, which promotes the model of a “dental home.” This approach encourages regular visits which improves the oral health of the family. To change your panel status, please contact the Network Development Assistant at 860-507-2307 for assistance.

Patient Record Sharing

According to Connecticut General Statutes, Section 20-7d, a copy of the patient’s record, including but not limited to, x-rays and copies of laboratory reports, prescriptions and other technical information used in assessing the patient’s condition shall be furnished to another provider upon the written request of the patient. The information provided should be readable and in the case of radiographs, of diagnostic quality. The written request shall specify the name of the provider to whom the record is to be furnished. A reasonable fee charged to the client is allowed. We ask that the fee be waived for our clients.

Charging for Goods or Services Provided by Clients

A provider shall not charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for any portion of the cost of goods or services which are covered and payable under the Connecticut Medical Assistance Program. If a client or representative has paid for goods or services and the client subsequently becomes eligible
for the medical assistance program, payment made by or on behalf of the client shall be refunded by the provider. The provider may then bill the medical assistance program for the goods or services provided. The provider shall obtain appropriate documentation that the payment was refunded prior
to the submission of the claim and shall retain said documentation.

Providers may not charge for medical goods or services for which a client would be entitled to have payment made, but for the provider’s failure to comply with the requirements for payment established by state regulations.

Providers shall only charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for goods or services which are not coverable under the Medical Assistance Program, when the client knowingly elects to receive the goods or services and enters into an agreement in writing for such goods or services prior to receiving them.

Annual Provider Surveys

Each year, CTDHP will contact providers to ensure that the information on file for each office remains accurate. The annual survey will be available online for providers to complete. Offices which do not use the online tool will be contacted by CTDHP to complete the survey via fax or mail. The survey takes approximately five minutes to complete. Your cooperation with completing the survey is greatly appreciated and will ensure that the referrals that are sent to you are appropriate to your current practice policies on age, geographic restrictions and special needs. A sample of the survey form is shown below.

Providers are encouraged to contact CTDHP with any updates to address, phone numbers, and languages spoken or special accommodations at any time of the year.

On Site Visits and Assessments

From time to time offices will be visited by a representative of CTDHP as we partner with you to ensure that your office is up to recent industry standards of sterilization, charting and patient safety. After a visit is completed, results and any improvement opportunities will be shared with you. A sample assessment form is shown below.

Marketing Guidelines

All marketing materials used for the CT Dental Health Partnership must be reviewed and approved by CTDHP and the Department of Social Services prior to use. Please submit a copy of your proposed materials for review to:
                   Connecticut Dental Health Partnership
                   Director of Network Development
                   PO Box 486
                   Farmington, CT 06032-0486

CTDHP and the Department of Social Services (DSS) will review materials submitted for approval and respond to review requests within sixty (60) days. If DSS does not respond to materials submitted for approval within sixty (60) days, the provider, provider group, facility or its representative(s) (referred to as
“Providers” going forward) may use the materials as presented. CTDHP or DSS reserves the right to request revisions or recall any materials that advertise or represent State or Departmental program(s) in advertisements or specific materials at any time. 

The following guidelines apply to marketing your services to CTDHP members (HUSKY Health or Covered CT Members). Please read them carefully.

Outreach Materials

All providers (individual providers, groups, facilities or programs) that provide dental services to Connecticut Dental Health Partnership HUSKY Health or Covered CT members must obtain prior approval from the Department of Social Services for all marketing activities, health education and all other materials.

Marketing materials that contain outreach information which targets CTDHP members (HUSKY Health or Covered CT Members):

Annual marketing plans and revisions to these plans as they concern CTDHP clients are subject to review. Submissions should include a description of the proposed marketing approaches, strategies, tactics and channels.

The State of Connecticut, Department of Social Services or any program logos and names in private marketing materials which target CTDHP clients are conditionally permitted. The program logo may be used in conjunction with and must be placed in the vicinity of the provider/provider’s office name. The font size for the statewide program phone number must not be smaller than the facility or provider’s office phone numbers.

Any alternative language including non-English translations must be prior approved by the  Department of Social Services.

Corporate marketing materials that include the Department of Social Services’ programs do not require prior approval if the materials exclusively promote the corporate brand and do not mention CTDHP, HUSKY Dental or any State of Connecticut or Departmental programs.

Truthful and Accurate Materials

All marketing materials must be truthful and accurate. Providers may not promote their offices through misleading, inaccurate or deceptive electronic, audio, printed or artistic materials. The Department of Social Services will not allow any information that it determines to be misleading or exaggerated. This
includes inaccurate statements regarding an individual’s eligibility, enrollment or program benefits, the positive attributes of the office/facility, or disadvantages of competing providers or facilities. 

Providers or their representatives must not present misleading or exaggerated claims about themselves, their offices or facilities’ positive attributes. Misleading references include advertisements that a provider’s services are free to any state, “Medicaid” or CTDHP members (HUSKY Health or         Covered CT Members).

Prospective clients could conclude from advertisements of this nature that only this particular provider/facility provides services or free services to CTDHP members (HUSKY Health or Covered CT Members. Providers/facilities may distinguish themselves by promoting their legitimate positive attributes. Providers may not present false or misleading statements that any of their products are endorsed by the Department of Social Services or the Center of Medicare and Medicaid Services (CMS) or any other government entity. Providers are also restricted from engaging in deceptive, fraudulent or
abusive practices for any purpose including enticing a client to become a patient and change their dental home.

Providers may not discriminate against any eligible individual on the basis of race, sex, age (including pediatric practices or facilities in the circumstances of older patients with special cognitive needs), creed, oral health status or the need for future oral health care services. In addition, discrimination based on sexual orientation; and gender identity and expression, is prohibited under state law.

Marketing Staff

The provider must not compensate marketing staff whether they are employees, independent contractors or marketing representatives through the use of a per client/patient incentive or a similar bonus type of reimbursement. Policies and procedures must be implemented to manage actions of the
marketing staff to ensure compliance with these marketing guidelines. These guidelines must be distributed to all of a provider’s offices and must require that the guidelines be followed at all offices located in Connecticut or in offices deemed to be “border town” offices or “out of state” practices. Providers may display DSS approved materials and brochures in their offices. All unapproved materials are mandated to be retracted.

Recruitment or Solicitation of New Patients

Providers or their representatives may not actively solicit new patients at other provider sites, offices or facilities. Marketing and solicitation materials may not be distributed at DSS eligibility offices, including those in hospitals or other facilities for the purpose of marketing or solicitation. Providers may provide
their materials to the DSS Central Office which will distribute the materials to regional operational centers for display purposes.

Providers may not market or promote their services through any means of telemarketing, mass mailings or any other means by which they may establish unsolicited personal contact with potential CTDHP members (HUSKY Health or Covered CT Members). Providers are permitted to respond with allowed
information to unsolicited phone calls from potential clients or patients and may return calls to them when they request a return call. The provider may also provide DSS-approved materials when requested by a potential patient. Providers may distribute marketing materials to its service area, but may not conduct personal, small group or face-to-face marketing meetings except as provided below.

Recruitment or Solicitation of New Patients through Events

Providers may not conduct promotional group meetings or individual solicitation with potential patients at provider offices or group offices, private clubs, private residences or employer sites. Providers may conduct outreach or market their services at events and meetings which are open to the general public including those held at public facilities, churches, health fairs, other community sites and those organized or sponsored if the provider notifies DSS in advance of such meetings by submitting to DSS on a monthly basis the schedules of educational and marketing events for the following month. The
schedules must contain enough information to allow DSS to attend events and monitor for compliance. Providers must utilize DSS approved materials in the presentations and comply with DSS’s marketing guidelines. Providers may only request name, address, phone number and family size from potential patients. Providers are not allowed at any time to request Social Security Number, date of birth, Client Identification Number, children’s names, family member names that are related to family members or future potential patients.

Gifts, Tokens and Incentives to Patients

The provider must not under any circumstances request or require personal contact information of potential patients in return for any gift item. Providers may distribute promotional token gifts of nominal value (toothbrushes, sample dental floss, magnets, pens, bags, etc.) at approved events and with approved materials to potential patients when DSS has approved the materials in advance of the distribution and the unit cost value of each item is less than  two dollars ($2.00) and the aggregate cost per potential client shall not knowingly exceed five dollars ($5.00) per occasion.

Providers may provide the following materials to CTDHP members (HUSKY Health or Covered CT Members) who are patients of record when DSS has approved the items and criteria for distribution:

• Token gifts to members including magnets, phone labels, and other nominal items that promote the dental providers services to reinforce “good” dental practices or behaviors
• Welcome packets sent to new patients of record
• Oral Health education materials which include but are not limited to podcasts, videos, CDs, DVDs, and other media

Providers must not provide or sponsor incentives unless explicitly approved by DSS. Such incentives include but are not limited to:

• Cash or gifts, including gift certificates or cards, to clients, patients of record or potential patients
• Gifts of any kind to agencies including DSS or its designee that hosts meetings with clients or potential patients
• Raffles in association with marketing related activities or for the purpose of collecting information for future marketing activities for potential patients
• Offering free screening and/or examinations and/or other dental services to potential or future patients or soliciting referrals from patients of record

Providers are encouraged to remind patients to utilize benefits including regular examinations and cleanings which are available and designed to promote good oral health at periodic regularly scheduled appointments. The provider may disseminate information solely regarding general oral health information materials to their patients of record without prior approval from DSS.

 

Utilization Management Programs

Utilization Management (UM) is a set of processes which seeks to ensure 

that eligible members receive the appropriate, least restrictive and most 

cost-effective treatment to meet their identified oral health needs within the prevailing standards of care. Utilization Management as used in this context includes practices such as, prior authorization, concurrent claims review, retrospective medical necessity review and retrospective utilization review.

Prior authorization includes prospective and concurrent claims review to 

ensure that services are delivered in accordance with the programs coverage guidelines, benefit rules and prevailing community standards of care. Retroactive medical necessity review may include provider chart reviews to ensure that documentation supports medical necessity and medical appropriateness of services and treatments rendered and that the documentation is consistent with the provider’s claims. These chart reviews may be random or targeted based on information produced during the utilization management process.

 

BeneCare has developed a sophisticated proprietary, multi-variable statistical approach to utilization management which seeks to explain an individual dentist or practice’s divergence from the average activity of all participating dentists by client group. The algorithm includes consideration of such
factors as the age and gender mix of patients seen, the doctor’s year of licensure, specialization or general practice, the socio-economics of the practice’s location and other variables. Utilization reports are generated for each dentist or practice that compares the dentist’s profile with the group norm.
Expected procedure frequencies are tabulated for every category of care, against which each dentist is measured. The profile highlights instances of both under and over-treatment when compared to the expected norm for the group using standard statistical measurement techniques.

Utilization management analyses are conducted periodically. Practitioners’ average care costs per patient are compared to the average cost of care for all patients under each dental specialty to further inform service distribution and practice pattern profiles. When a dentist’s utilization patterns are outside of the confidence interval limits calculated in the statistical model or their average costs per patient are in variance to the average costs per patient generally, a more detailed utilization management investigation may be conducted.

Based upon these findings, communications from CTDHP detailing the variance in practice patterns or care costs and detailing the areas of concern will be sent to practitioners requesting a response that either explains the variance from expected norms or affirms an understanding of the areas of concern
and agreement to modify practice patterns which led to the observed outcomes.

 

Non-compliance with these communications efforts may lead to further corrective action being initiated, which may include:

• Random or selected chart audits
• Referral to the Department of Social Services Quality Assurance Unit
• Practitioner specific modifications to future prior authorization and claims review requirements
• Terminating the dentist from the network